Authorization for Medical Treatment

First Name of Camper*Last Name of Camper*First Name of Parent or GuardianLast Name of Parent or GuardianEnter any special dietary concernsEnter any special medical concerns

Insurance Information

Name of Insurance*Policy Number*Group Number*Address*City*State*ZIP Code*Telephone Number (no dashes)*

Dental Insurance Information

Name of Insurance*Policy Number*Group Number*Address*City*State*ZIP Code*Telephone Number (no dashes)*

By clicking on the submit button below, I accept the conditions as specified in this Authorization for Medical Treatment. I authorize the Camp Director or his/her representative to act on my behalf should I (or my child) become the victim of a major accident, injury, or illness when immediate medical or surgical care is needed, provided the Director, or his/her representative shall, when possible to do so, make diligent effort first to obtain my preferences. If it is not possible to obtain my preferences, I authorize the Director, or such staff designated to act in his/her stead, to take such actions and give such consent on my behalf as their judgment dictates.

In the event that the Director or his/her representative must agree to be the guarantor for fees incurred at a medical facility in order for me (or my child) to receive treatment, I agree to pay all fees that may be charged to that individual. I understand that medical facilities may bill me for any portion of those fees which are not covered by insurance. The Director or the staff acting in his/her stead and the camp staff have my authorization to obtain from other physicians, hospitals, or health care facilities, any medical information they need to provide me (or my child) with continuing health care while at the TKA summer karate camp.

CaptchaBy clicking on the submit button I signify that I agree to authorize any medical treatment.*

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Thank you for submitting your insurance information and authorization for medical treatment online.

If you have any questions or need any additional information, please call the TKA office at +1.301.840.9262. Thank you.